As plan sponsors seek new ways to contain rising specialty drug costs, with particular emphasis on increased formulary management, one area that continues to generate a lot of buzz but little action from health plans and PBMs is specialty drug coupons. When asked for the second year in a row if they are considering or had deployed any strategies to curb the use of widely available discount programs that may hinder the preferring of specialty products, many indicated that they were evaluating strategies.

Based on the success of a copay coupon elimination pilot launched in 2013 covering six medications chosen because of the availability of lower cost, therapeutically equivalent options, UnitedHealth Group’s UnitedHealthcare unit has expanded the program to cover an additional 25 medications as of Jan. 1, 2014 (DBN 10/25/13, p. 1). The eliminations impact less than 1% of UnitedHealthcare members currently taking one of these drugs, and the action does not apply to needs-based assistance programs.

While it did not take as calculated an approach, Express Scripts Holding Co. recently updated its National Preferred Formulary by removing 48 products based on recommendations from its pharmacy and therapeutics committee “to ensure clinical appropriateness.” Most of those agents were linked to copay coupons, and included several specialty drugs, such as the new oral rheumatoid arthritis drug Xeljanz (tofacitinib) as well as older, more commonly used agents such as the multiple sclerosis treatment Betaseron (interferon beta-1b) (DBN 10/25/13, p. 8). Express Scripts’ Adam Kautzner, Pharm.D., senior director of drug trend and formulary solutions, says clients are asking the PBM to apply this approach to other high cost and increasingly competitive drugs, both traditional and specialty, in 2015 and beyond. Meanwhile, Express Scripts client BlueCross BlueShield of Tennessee tells DBN it has considered the value of limiting specialty drug coupons but has not taken steps to implement anything at this point.

“Specialty coupons and patient assistance programs can be effective programs to help members offset high out-of-pocket costs, but coupon use should not circumvent existing utilization management programs, care management programs or formulary management strategies,” observes Prime Therapeutics LLC Senior Director of Health Outcomes Steve Johnson. While Prime currently relies on prior authorization and step therapy as the primary modes of reducing the utilization of nonpreferred specialty agents, it will “continue to evaluate strategies to promote preferred specialty drugs while considering the effect on prescription abandonment and adherence,” says Johnson.

“The pharmaceutical industry needs to understand the fact that pushing all what they manufacture by all means is no more a marketing strategy that will be tolerated by the health care provider/payer community,” weighs in Mesfin Tegenu, R.Ph., president of PerformRx, LLC, a PBM that is a fully owned subsidiary of the AmeriHealth Caritas Family of Companies. To deter the use of coupons for nonpreferred or nonformulary drug products, PerformRx says it will implement programs such as “increasing the differential for the nonpreferred products to the point that the financial consequences of using a coupon make the transaction cost prohibitive to the member (the after-coupon price is still higher than the cost of the preferred agent) and financially neutral to the health plan (post-coupon cost is the same as the cost of the preferred agent),” he explains in an email to DBN.

MedImpact Healthcare Systems, Inc. adds that it supports clients who believe the use of drug coupons on nonpreferred specialty medications eliminates the incentive for patients to move to a preferred drug, and is considering the exclusion of some nonpreferred specialty products where clinically equivalent therapeutic alternatives exist.

Some Will Rely on PA, Site of Care

Declining to comment on the coupon issue, Aetna Inc. says it is directing its specialty pharmacy efforts more to “site of care and sourcing of pharmaceuticals to the most cost-effective providers,” adds Edmund Pezalla, M.D., national medical director for pharmacy policy and strategy.

While OmedaRx (formerly RegenceRx) is concerned about appropriate use of certain high-cost specialty agents, “we have prior authorization that’s necessary and in some cases we would require the use of one product before we would cover another product, so under those circumstances the copay cards aren’t really going to impact our utilization,” asserts Sean Karbowicz, Pharm.D., director of clinical evaluation and policy. “At the same time, these medications are very expensive and if there are programs that make them less costly for people who truly need them and particularly [for] indigent patients, then we want to support and do what we can to make sure these medications are available and affordable. It’s a balanced picture, I think.”

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